This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.
Discussing: Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012, Vol 40(8). 2479-2485
- This 2012 meta-analysis demonstrated that catheter-related blood stream infection (CRBI) risk is no different between internal jugular, subclavian, and femoral catheter insertion. The authors demonstrated that previous level 1A guidelines regarding femoral catheter infectious risk were in error.
- The overall risk of CRBI is declining over the recent years and likely due to the combination of more precautions at the time of insertion as well as vigilant management of the catheter once placed.
There is significant morbidity and mortality associated with CRBI. In the United States alone, an estimated 30-60 thousand patient deaths occur annually secondary to this infectious process. In 2011 a clinical recommendation from respected organizations including the CDC’s Healthcare Infection Control Practices Advisory Committee as well as the Infectious Disease Society of America issued a class 1A recommendation to “avoid using the femoral vein for central access in adult patients.” This recommendation would suggest that there is strong supporting data including at least one well performed RCT. The purpose of this meta-analysis by Marik and his colleagues was to call into question the validity of such an absolute statement. Marik and his partner Flemmer performed an exhaustive literature search and were able to find 2 RCTs and 8 cohort trials to include in their meta-analysis. This literature review was more comprehensive then the citations provided by the societies issuing the level 1A recommendations. There study, however, focused solely on the question of CRBI and did not address concerns other concerns associated with central venous access such as injury to nearby structures, DVT, or bleeding.
This study reviewed more data than the 1A recommendation from the CDC and IDSA and could not find compelling evidence that the femoral vein should be avoided for concerns of CRBI. Furthermore, it appears that the universal precautions that are being used currently have likely led to an overall decrease in CRBI compared to the years past. For example, the rate of CRBI in the United States in 1998 was 5.32/1,000 catheter days and has subsequently dropped to 2.05/1,000 in recent data. The Welsh Healthcare Associated Infection Program which is the largest collection of data and noted that in over 55 thousand catheter days in 2009 and 2010 there were only 0.61/1,000 catheter day infectious risk with no difference between insertion sites. Marik and his colleagues therefore note that the site of preference should “depend on the expertise and skill of the operator and the risks associated with placement.” The authors recommend against using femoral vein catheters in renal transplant patients, patients who would benefit from early mobilization as well as the massively obese due to a subgroup analysis in the Parienti study that noted worse outcomes in these individuals.
The average CRBI density in the compilation of trials was noted to be 2.5 +/- 1.9 per 1,000 catheter days (range 0.6-7.2). In compiling the data it was noted that two of the cohort trials, Lorente and Nagashima, appeared as statistical outliers increasing the heterogeneity of the meta-analysis significantly. It is unclear why these two trials demonstrated a more than two-fold increased risk of CRBI with femoral catheter insertion. If these trials were removed from the data the authors noted that there appeared to be no heterogeneity within the study (RR 1.02, 95% CI 0.64-1.65, p = 0.92, I² = 0%). This study also performed a meta-regression that appeared to demonstrate a significant interaction between the risk of infection and the year of publication (p = 0.01).
Level of Evidence:
Based on the design of this study, including RCTs and cohort trials, with a few limitations this study was graded a level III based on the ACEP Clinical Policy Grading Scheme for meta-analyses.
In many aspects of medicine it is curious to see how wide practice variation can be, especially when considering geographic and healthcare system influences. This notion is highlighted by reviewing the different guidelines within this meta analysis by various public health/safety committees across the United States and United Kingdom.
Lorente, L. Henry, C. Martin, MM. et al. “Central Venous Catheter-Related Infection in a Prospective and Observational Study of 2, 595 Catheters.” Crit Care, 2005 9. R631-5
Nagashima, G. Kikuchi, T. Tsuyuzaki, H. et al. “To Reduce Catheter-Related Bloodstream Infections: Is the Subclavian Route Better than the Jugular Route for Central Venous Catheterization?” J Infec Chemother, 2006 12. 363-65
Parienti, JJ. Thirion, M. Megarbane, B. et al. “Members of the Cathedia Study Group: Femoral v. Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial.” JAMA, 2008 299. 2413-22
Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012 Vol 40(8). 2479-2485
Anatoly Kazakin MD